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    Out - Patient Assessment and Evaluation Form

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    Aina Haravata
    The document is an outpatient assessment and evaluation form containing fields for a patient's name, age, sex, date of consultation, birthday, contact number, PhilHealth status, address, initial vital signs including temperature, heart rate, respiratory rate, blood pressure, oxygen saturation, fetal heart tone (if applicable), weight, and height. It also includes sections for the clinician to note their assessment, diagnosis, planned laboratory tests and diagnostics, and treatment plan. The form is signed by the attending resident physician.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Out - Patient Assessment and Evaluation Form

    Uploaded by

    Aina Haravata
    837 views1 page
    The document is an outpatient assessment and evaluation form containing fields for a patient's name, age, sex, date of consultation, birthday, contact number, PhilHealth status, address, initial vital signs including temperature, heart rate, respiratory rate, blood pressure, oxygen saturation, fetal heart tone (if applicable), weight, and height. It also includes sections for the clinician to note their assessment, diagnosis, planned laboratory tests and diagnostics, and treatment plan. The form is signed by the attending resident physician.

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    OPD SLIP(new)

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    The document is an outpatient assessment and evaluation form containing fields for a patient's name, age, sex, date of consultation, birthday, contact number, PhilHealth status, address, initial vital signs including temperature, heart rate, respiratory rate, blood pressure, oxygen saturation, fetal heart tone (if applicable), weight, and height. It also includes sections for the clinician to note their assessment, diagnosis, planned laboratory tests and diagnostics, and treatment plan. The form is signed by the attending resident physician.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    837 views1 page

    Out - Patient Assessment and Evaluation Form

    Uploaded by

    Aina Haravata
    The document is an outpatient assessment and evaluation form containing fields for a patient's name, age, sex, date of consultation, birthday, contact number, PhilHealth status, address, initial vital signs including temperature, heart rate, respiratory rate, blood pressure, oxygen saturation, fetal heart tone (if applicable), weight, and height. It also includes sections for the clinician to note their assessment, diagnosis, planned laboratory tests and diagnostics, and treatment plan. The form is signed by the attending resident physician.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 1

    OUT – PATIENT ASSESSMENT AND EVALUATION FORM

    NAME: __________________________________________ AGE: _____ SEX: ____ DATE OF CONSULTATION: mo. _______ / day _____ / yr. ________

    BIRTHDAY: ______ / _____ / ______ CONTACT NUMBER: ____________________________ PHILHEALTH: NH l NM


    l Month Day Year

    ADDRESS: __________________________________________________________________________________________________________

    INITIAL VITAL SIGNS:

    T: _______ °C ASSESSMENT: __________________________________________________________________

    HR: ______ bpm ______________________________________________________________________________

    RR: ______ bpm DIAGNOSIS: ____________________________________________________________________

    BP: _______ mmHg ______________________________________________________________________________

    O2 SAT: _____ % LABORATORY AND DIAGNOSTIC PLAN: ______________________________________________

    FHT: _______ bpm ______________________________________________________________________________

    WT: ________ TREATMENT PLAN: ______________________________________________________________

    HT: _________ ______________________________________________________________________________

    _______________________________, MD
    Signature over Printed Name
    Resident on Duty
    License No:

    OUT – PATIENT ASSESSMENT AND EVALUATION FORM


    NAME: __________________________________________ AGE: _____ SEX: ____ DATE OF CONSULTATION: mo. _______ / day _____ / yr. ________

    BIRTHDAY: ______ / _____ / ______ CONTACT NUMBER: ____________________________ PHILHEALTH: NH lNM


    Month Day Year

    ADDRESS: __________________________________________________________________________________________________________

    INITIAL VITAL SIGNS:

    T: _______ °C ASSESSMENT: __________________________________________________________________

    HR: ______ bpm ______________________________________________________________________________

    RR: ______ bpm DIAGNOSIS: ____________________________________________________________________

    BP: _______ mmHg ______________________________________________________________________________

    O2 SAT: _____ % LABORATORY AND DIAGNOSTIC PLAN: ______________________________________________

    FHT: _______ bpm ______________________________________________________________________________

    WT: ________ TREATMENT PLAN: ______________________________________________________________

    HT: _________ ______________________________________________________________________________

    _______________________________, MD
    Signature over Printed Name
    Resident on Duty
    License No:

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